Effects of hypokalaemia on the ECG

Decreased extracellular potassium causes myocardial hyperexcitability with the potential to develop re-
entrant arrhythmias

ECG changes when K+ < 2.7 mmol/l

 Increased amplitude and width of the P wave
 Prolongation of the PR interval
 T wave flattening and inversion
 ST depression
 Prominent U waves (best seen in the precordial leads)
 Apparent long QT interval due to fusion of the T and U waves (= long QU interval)

With worsening hypokalaemia…

 Frequent supraventricular and ventricular ectopics
 Supraventricular tachyarrhythmias: AF, Atrial flutter, Atrial tachycardia
 Potential to develop life-threatening ventricular arrhythmias e.g. VT, VF and Torsades de Pointes

T wave inversion and prominent U waves in hypokalaemia

Long QU interval in hypokalaemia

Handy tips

 Hypokalaemia is often associated with hypomagnesaemia, which increases the risk of malignant
ventricular arrhythmias
 Check potassium and magnesium in any patient with an arrhythmia
 Top up the potassium to 4.0-4.5 mmol/l and the magnesium to > 1.0 mmol/l to stabilise the
myocardium and protect against arrhythmias – this is standard practice in most CCUs and ICUs